The purpose of this bulletin is to provide a current summary and analysis of information available both in general media and especially from Chinese and international scientific sources regarding the coronavirus outbreak in and disseminated from Wuhan to other Chinese cities, and then to many countries around the world, and to make specific recommendations for each of the client groups, national travelers, expatriates in the targeted areas, and international travelers, both corporate and leisure, as well as to Generali Global Assistance/Europ Assistance’s own staff.

Overview

This outbreak started officially December 31st 2019 in a live animal and fish market in Wuhan and is thought to originate from the Chinese horseshoe bat. It initially caused relatively few cases, was managed with energetic local isolation measures, and showed no evidence of human to human contagion. Recommendations were therefore limited to avoiding contacts with animals and patients, and no travel restrictions were advised by either Chinese or international authorities. A significant deterioration of the situation in China was reported by the media over the January 18th weekend and has been increasing ever since, first in China and then worldwide. It was confirmed the following week by the Chinese authorities, including the transmission, probably through droplets, between human beings. The disease is highly contagious but appears less severe than SARS or MERS at this stage. The proportion of severe cases has stabilized around 15% of the total number of cases. Deaths, at around 4 % overall but with wide variation between high (Iran, Italy) and low (Germany, Austria, South Korea), occur mostly in older people above 70 years of age, most with underlying diseases such as diabetes, chronic pulmonary diseases and cardiovascular diseases. The signs and symptoms to watch for are first of all contact with a proven or potential case or environment, then respiratory symptoms like cough and dyspnea / shortness of breath and feeling sick. Fever is often but not always present. A significant incidence of anosmia (loss of smelling sensation) is now also reported. The incubation is usually 3 to 7 days, rare cases are transmitted from symptom free patients, and the maximum is currently thought to be 14 days although there may be cases exceeding this length.

The World Health Organization (WHO) has congratulated the Chinese authorities for their efforts in the fight against this outbreak and their contribution to research. It declared a Public Health Emergency of International Concern on January 30th 2020 in view of the growth in the numbers and the restrictions applied by China and many countries. It supported the Chinese initiatives but strongly argued against the global spread of any measure to restrict travel as economically unsound. The WHO cooperated with IATA to standardize precautions onboard airlines and has worked with ICAO to make joint recommendations. On February 11th 2020 to be coherent with international virus and disease naming rules the International Committee on the Taxonomy of Viruses renamed the virus SARS-CoV-2 and the WHO named the disease COVID-19. The March 3rd edition is important because it reminds all of the definition of cases. A suspect case either has a combination of fever and one respiratory symptom and a history of travel to or contact with a source of COVID or a patient with severe respiratory illness and no other etiology. The case becomes confirmed with a positive test irrespective of symptomatology. On March 5th the WHO’s director general made a strong appeal to all countries to take the situation seriously and to put in place measures to reduce the transmission of the disease. He warned against misinformation related to media spreading too many uncontrolled news and insisted on the importance of balance and coherent communications. The February 29th travel recommendations have remained unchanged, but the March 10th situation report clearly and rightly warns against any limitations in international travel not objectively founded on the reduction of infection transmission.

On March 11th the WHO’s Director General declared that this outbreak now qualified as a PANDEMIC. The next day he declared that this pandemic must be considered CONTROLLABLE. ICAO and the WHO have issued a joint statement to support guidelines to mitigate risks in the travel industry, but there is no statement regarding the maintenance or not of air travel capabilities. The focus of the recommendations remains on decreasing contacts likely to increase contamination and early access to formal isolation and proper treatment for positive cases. On March 18th the WHO’s DG Dr. Ghebreyesus, highlighted the need to insist on the focus on the four key priorities, isolate, test, treat and trace. He congratulated Korea for succeed in one month to reduce cases from 800 to 90. The WHO has insisted on the need to develop access to testing and to an optimization of equipment procurement.

Most governments are now advising that anyone showing symptoms related to COVID-19 is asked to remain isolated and to contact the emergency services (112 or the equivalent). The key preventive measures are targeted towards avoidance of contact with potential sources of contamination, hygiene and strictly restricting diagnosis and treatment to facilities designated by the authorities. The need for avoidance of contact to reduce contamination has led many countries to enforce house confinement measures similar to the ones seen in China a month and a half ago.

Travelers and expatriates have to realize that several countries have seriously reduced access to activities in their countries. When possible accelerated return to the home countries is an appropriate strategy especially if the situation at home is less challenging than at the client’s current location. First and foremost are the cancellation of any crowd event, including sport competitions and the closing of schools, but several countries have gone beyond this and reduced access to shops, to elective health care, to restaurants and early return home may have to be considered if flights are still available, sometimes through modified itineraries. Increased testing may have added value as well as improved availability of protection devices- especially masks – and essentially for caregivers, public service officials and COVID-19 positive patients. Given reduced air traffic and increased administrative restrictions at borders, travel is more and more difficult for clients even returning home in good health. These constraints are even worse for escorted commercial flights as escorts run the risk of being quarantined, and the risk exists as well for air ambulances. Transport of COVID positive cases although reported in very rare cases must not be considered as an option at all. Local care in suitable facilities is by far preferred. There have also been serious difficulties in handling the bodies of COVID-19 victims, both nationally and internationally.

Current global situation

At this stage the latest modified data available, as of 17H00 March 27th China time, the total volume of confirmed cases in China was 82613, and 3298 deaths had occurred. A total of 536354 cases and 16419 deaths have been identified worldwide, a continued marked increase that shows that the problem is global and currently most acute in Western Europe. The general situation of the epidemic is improving in China and the confirmed case volume is continuing to decrease as more and more healed cases, over 75% of the total cases, emerge. New cases continue to occur mainly at entry points like international airports. There have been no new local cases in Hubei province, the starting point of the epidemic, yesterday, a legitimate source of pride for China and an encouragement for other countries. Another positive sign is the re-opening of public transport in Wuhan. China is concerned about imported cases at this stage and has stopped allowing foreigners to enter the country.

Initially many countries implemented travel restrictions to and from China, but the number of affected countries has increased significantly, and many measures have been taken by many countries to reduce or forbid access to their territory to anyone directly or indirectly coming from a high contamination risk country. Therefore, it has become imperative for people to enquire about any limitations with the Generali Global Assistance/Europ Assistance. Generali Global Assistance/Europ Assistance will ensure that accurate and up to date information is provided in addition to adapted assistance services, always aligned to government advice. The number of such cases is expected to decrease as very few travelers remain and even many expatriates have left. However, tens of thousands of foreign travelers are still stranded in non-critically COVID tourist destinations and several governments are organizing transport back home.

Europe

Italy, with 80589 cases and 8215 deaths, Spain (57786 and 4365), Germany (45014 and 273), France (29556 and 1698, and the UK (11812 and 580 have high rising numbers which challenge the capability of the overwhelmed health care delivery systems in many areas. The variation in the death rate may in part be linked to differences in the availability of resources but the interpretation must be careful as there may well be differences in the way the numerator is calculated. Many old age homes have become clusters for death cases (sometimes not included in the mortality figures).

Since the week of March 16th, the situation has evolved dramatically in Europe as cases escalate. Italy took further steps to lock down the entire country and currently all travel into or out of is banned unless there are urgent reasons to do so and most governments have recommended a halt to all travel to Italy, with subsequent mass cancellation of flights. Italian citizens are being urged to remain at home – unless they have an urgent health or work reason or purchase food and household cleaning products or medicine.

Subsequently, action has followed across the rest of Western Europe. The measures taken vary country per country however most countries have adopted the closure of schools and universities, sporting events and mass gatherings while others have gone further to issue travel restrictions and in the case of several countries strong measures on border control to limit entry to nationals and sometimes control health status in addition. In all cases the evolution is toward home confinement as is already the case in China, Italy, Spain, France, Belgium and Portugal, and many other countries (even the UK). Several countries and regions have added curfews to further reduce transmission potentials.

Asia

Although it was hit early, right after China, Asia has resisted quite well with the exception of Iran, which accounts for 29406 cases and 2234 deaths of the continent’s 59860 cases and 2776 deaths. South Korea has a large number of cases (9332, very few of them recent) but relatively few deaths (139). This is probably due to the strong health infrastructure response and access to easy screening as in Japan and SE Asia. India remains a question mark. There is a rise in cases in India, which just introduced a three weeks lockdown.

The Americas

The USA are now the country with the most cases, 85991, as well as 790 deaths, and the government has acknowledged the extent of the challenge and began to restrict travel into the country, with week March 16 seeing the introduction of a travel ban to a number of European countries. California was the first state to introduce a lockdown, followed by others including New York, now the hardest hit is in the country. The number in South America is spread out and totals 7853 cases but so far only 147 deaths. A number of South American countries have restricted flights to Europe while Peru and Ecuador have enforced a lockdown, similar to those seen in Europe.

Oceania

Similarly to South East Asia, Oceania has relied on the strong public health response, with a relatively but rising low number of cases 3612 and with only 13 deaths so far. New Zealand will enter into a European style lockdown, closing all non-essential activity.

Africa

Africa has a low but growing number of cases, 3485 and 93 deaths but is doing its best together with international organizations to prepare as the impact could be severe given the relatively weak public health infrastructures.

Generali Global Assistance/Europ Assistance Recommendations

In these circumstances Generali Global Assistance/Europ Assistance recommended, to first and foremost avoid any contact with patients with COVID-19, and more generally with patients with cough and fever. This is also recommended to national clients. Of course, the usual hygiene precautions should remain a priority considering that regular handwashing, disinfection and adequate use of mask wearing, especially in public transport and crowded places, are part of these essential hygienic attitudes. For expatriate patients planning to remain in these countries one would suggest avoiding exposure to mass transport, visits to hospitals and clinics, as well as to markets with live fish and animals. In addition, a worldwide push to reduce social interaction between people to reduce contamination is supported by Generali Global Assistance/Europ Assistance, all the way to and including confinement for periods of weeks. We also support access to proper hospital beds, masks and testing.

For those seeking to enter or exit countries or regions with government-imposed restrictions will face severe travel restrictions.Expatriate wishing to travel back, and travelers should take into account the measures and travel restrictions issued by several governments, and the fact that many airlines have temporarily suspended flights.As mentioned earlier some governments are acting to decrease the backlog of nationals remaining abroad. Clearly any travel undertaken have formal restrictions were announced could be challenged cover wise. For non-essential travel to China the sensible individual decision may be to delay travel for several days until the information regarding this epidemic is more reliable. These considerations concern China, Korea, Iran and Italy as there are at least administrative reasons if no medical reasons to restrict travel anywhere in first and foremost Europe, then Asia or the rest of the world because of the COVID-19 epidemic. There is an increasing risk that countries, Thailand, Israel, Czech Republic, Denmark or Morocco being examples, put restrictions in place for travelling visitors from affected countries thus reducing access to care even to people with no COVID-19 issue. We will continue to offer air ambulance evacuations and repatriations for non COVID 19 cases despite the difficulty but insist on the fact that requesting the return of COVID cases is almost always inappropriate.

Our internal procedures are until further advise to ensure negative test for COVID-19 has been carried out for any Generali Global Assistance/Europ Assistance patient with respiratory disease, who travels by air (air ambulance or commercial carrier) from any affected country to any other country. Patients no matter where they are must monitor signs of infection, fever and respiratory symptoms and follow local rules after calling their Generali Global Assistance/Europ Assistance platform before seeking care. In general, if positive they will be asked to remain in isolation for 14 days if not very sick, or to be cared for locally.

In addition, it is important to stress that individuals who show symptoms of the Coronavirus must not visit the supermarket or pharmacy, even in lockdown cases. They must contact the public health authorities.

Generali Global Assistance/Europ Assistance has provided detailed information with simple prevention measures for employees, partners and corporate clients. These will be centered on minimizing contacts by increasing work at home, reducing physical meetings, and even reducing usual means of showing friendship such as handshakes and kisses. It emphasizes the need for frequent handwashing with soap and water, plus, wherever appropriate alcoholic disinfectant. These should be provided at offices. Masks should be used by anyone dealing with potential patients, people living in the same room as suspect cases, and of course people with symptoms. They are marginally useful otherwise to protect healthy people from getting the virus.

We encourage our readers to nevertheless consider the situation as one that will be overcome, especially if governmental restrictions are adhered to, and to remember that most people affected will not be seriously ill. The key is adherence to public health advice. Generali Global Assistance/Europ Assistance cares for its clients and its employees and will do everything to help.

The current bulletin will be updated regularly until the situation stabilizes.

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